Prior Day Hospital Admission

HMSA's medical plans are designed to encourage outpatient pre-admission care whenever appropriate. Because our medical plans include coverage for outpatient preadmission screening and testing, most patients requiring surgery are not admitted until the date of surgery.

In some cases, we have found that pre-admission care that could be performed in an outpatient setting is being done on an inpatient basis prior to surgery. While a prior-day admission may offer certain conveniences, it could result in increased cost to your patient.

Our prior-day hospital admission guidelines were developed to accommodate situations in which hospitalization prior to the date of surgery is medically appropriate. If hospital admission on the same day of the surgery creates a significant risk to your patient and could result in increased post-surgical complications or length of inpatient stay, the patient may be admitted on the day prior to the surgery.

Examples

The following are examples of patients whose medical conditions may require extensive preparation prior to surgery. In these and other similar situations, prior-day admission may be warranted:

• A patient with significant medical risk factors that could compromise the patient's outcome and recovery (such as a brittle diabetic undergoing major surgery, who has documented evidence of having tried unsuccessfully to stabilize blood sugars on an outpatient basis)
• A patient with severe, multiple system disease requiring study and treatment before surgery or further treatment (for example, a patient who needs hydration, intravenous antibiotics and intestinal decompression)

Claims Filing Information

For outpatient preadmission laboratory work-ups or X-ray services, please be sure to give the laboratory or radiology provider the patient's primary diagnosis, as well as any complicating secondary diagnoses that require the outpatient pre-admission tests to be performed.

Some HMSA plans provide a higher level of benefit coverage for prior-day admission testing. Please inform the laboratory or radiology provider that the testing is "prior-day admission testing" the provider needs this information for inclusion on the claim for lab or X-ray services.

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